Compelling commentary on children's health

It’s always been in breast milk, then it appeared in infant
formula and now you can find it in baby food.It’s DHA (docosahexaenoic acid).So what
is DHA and do you need to be feeding your baby DHA-supplemented baby food?

What is DHA? DHA
is a special fatty acid critical to brain and eye development in babies and
young children.Babies get a bunch
of it during the last trimester of gestation and then become dependent upon
getting DHA in their diets.DHA is
found in breast milk (as it turns out, levels in breast milk depend upon your
diet) and it first was added to infant formula here in the U.S. in 2002.

What does it do?Studies have shown that DHA, when added
to a baby’s diet at certain levels, can improve brain development and vision.While this was initially felt to be
true only in preemies, recent studies have supported a neurodevelopmental role
for DHA in term babies.And if
that is isn’t interesting enough, try this on for size: A new study released
this summer (abstract findings presented at the World Congress of Pediatric Gastroenterology, Hepatology and Nutrition) found a tight connection between DHA exposure in infancy and
resistance from upper respiratory infections later in childhood.Wow.While its suspected that the effects reported in this study
may be seen with the levels of DHA found in Mead Johnson’s Enfamil Lipil or
Nestle Good Start, the study was conducted among children fed Enfamil Lipil.

Here’s the problem. When it comes to brain and eye
development, no one knows exactly how much DHA a baby needs.Several organizations have taken a stab
at minimums but they’re nothing better than a stab.And these stabs are based on minimum levels proven
to make a difference.The American
Dietetic Association, for example, has suggested that infant formula contain at least 0.2%
of its fatty acid content as DHA.The American Academy of Pediatrics has been conspicuously silent on DHA
since its introduction into infant formula.

So back to our
question.Do children need DHA
in their baby food? No one knows
the answer to this question.While
we may accept the mounting data showing that certain levels in infant formula when taken at standard baby volumes are associated with improved brain development and vision, there’s no evidence that
the addition of more DHA in baby food offers any advantage.

But as with most elements of our baby’s diet,
the body takes what it needs and what remains feeds the Diaper Genie.And so it may be with DHA.But at least we all feel good believing
we’ve tried to make a difference.

I call it the Great Wall of Formula at Babies R Us.It’s that quarter mile long aisle of
infant formulas that's supposed to hold the ticket to a content, care-free
baby.But if you spend any time there
you’re apt to wind up more bamboozled than anything else.

Here’s why: Your baby doesn’t need most of ‘em.

Let’s talk about 4 types of formula your baby will likely
never need:

Lactose-free formula. As a baby stomach specialist at the largest children’s hospital in the
U.S. I have yet to figure out why lactose-free formula is produced.This is a formula without any
indication.It is a regular old
cow’s milk based formula without lactose.But here’s the problem:babies don’t have issues with lactose.While there is a brief period during the first week of life
when babies don’t produce lactase (the enzyme in the lining of the intestine for
digesting lactose), a baby’s body universally kicks in and produces lots of
lactase.

Here’s what formula manufacturers want you to think:Lactose-free formula is for babies with
milk allergy.But it has all the
milk protein of a standard infant formula so we would never use a lactose-free
formula in cases of milk protein allergy.Not nowhere, not no how.This
is a market-driven formula placed on shelves with the sole purpose of
bamboozling you, the parent consumer.

Soy formula.Soy
formula is one of the oldest infant formulas on the market and represents about
20% of all infant formula sold.But it’s a bit of an oddball – there’s really no clear medical reason
why any baby would need it.Allergy perhaps?No,
definitely not.Approximately 50%
of babies allergic to standard cow’s milk formula will react to soy.Soy formulas are lactose free but as
we’ve learned, lactose free formulas are almost never medically necessary in a
baby.But what about parents who
want to avoid any type of animal products?While I’ll concede this as one of the textbook roles for soy
formula, I have never encountered a parent who has chosen it for this
reason.Most are so driven to
breastfeed that the issue of formula is never addressed.

Low-iron formula.Among the great urban legends circulating in pediatric offices worldwide
is the idea that iron in infant formula causes constipation.But the fact is that no such
association exists and it has been proven in multiple blinded, controlled
studies (you can find them here and here).And as someone who has made a career working with the most
constipated of the constipated, I can attest to the fact that there’s no
connection.In a previous post I
run the numbers illustrating the potential dangers of low-iron infant
formula.And at the risk of
repeating myself, low-iron formulas have no place on store shelves or in your
diaper bag.

Mead Johnson made the right decision for babies by
discontinuing their low-iron preparation last year. As of recent I see that Similac low-iron is no longer available. Hopefully, this is the end of the road for low-iron formula.

Toddler formula.I’ve been a pediatric gastroenterologist for over 10 years and I’ve yet
to find a patient who needs a toddler formula.After weaning from the breast of bottle, toddlers almost universally
meet their needs with solid food and a variety of drinks including a little bit
of milk.Admittedly toddler
formulas offer a more appropriate balance of iron and vitamins than cow’s milk,
the point is moot in all kids except the most miserable of feeders.And in this case we’ll often supplement
with something even more complete than a toddler formula – I like Nutren Jr. or
Pediasure.Save your money and
avoid toddler formulas unless your pediatrician has a very good reason.

So breastfeed if you can.And if you use infant formula, remember that it’s unlikely
that your baby will ever need anything other than Nestle Good Start (I like Good Start with Natural Cultures), Enfamil Lipul, or Similac.But talk to your doctor, ask questions
and don’t forget that an informed parent is an empowered parent.

So it’s looking like the great U.S. melamine scare of 2008
has appropriately turned out to be a big nothing.If you missed it, the FDA reported small amounts of melamine
in all three of the major formula manufacturers here in the U.S.And if you’ve really had your head in
the sand, melamine is the stuff that Chinese milk suppliers were using to
create the appearance that their milk was better than it was.The result was 50,000 babies with
kidney stones and a few deaths.

So it was true that the FDA found trace amounts of melamine
in U.S. formula but at levels that are barely detectable.To illustrate, this is the equivalent
of one drop of melamine in 64 gallons of infant formula.Or 10,000 times of that seen in the
China scandal.But there’s no
scandal here.As it turns out the
miniscule levels found here were the result of a solution used to clean
manufacturing equipment.Not an
excuse by any means but certainly an explanation that doesn’t suggest scandal
or appreciable risk.This is a
bigger PR problem than a medical problem.

So should parents switch formulas?As an industry-wide finding this wouldn’t appear to make any
sense.Sit tight and recognize
that in the scheme of environmental exposures to lose sleep over, this ranks
twenty or thirty on my list of parental worries.

Should I breast feed?Of course you should breast feed.But not everyone can breast feed and not everyone breastfeeds forever.I’m not able to find any studies on
Pubmed that have evaluated melamine transmission in breast milk.Remember that when it comes to
environmental substances, breast milk isn’t always the solution we wish it
were.What mom gets baby often
gets.Think bisphenol-A,
unfortunately.

While the formula industry has been conspicuously silent on
the issue, I haven’t.You can see
me on Houston’s Fox News Channelhere.

Maryland’s Howard County Health Department has taken the step of providing only bisphenol A-free products to its WIC (Woman’s, Infants and Children) Program. WIC provides supplies and supplemental foods to low-income pregnant women, new mothers, infants and children under the age of 5. According to Maryland Med, Dr. Peter Beilensen, Howard County’s top health official “hopes to turn BPA into another trans fat: legal but largely shunned by the public.”

As far as I can tell this is one of the first WIC programs in the country to take a firm stand on BPA. But here’s the $64,000 question: Will the Howard County Department of Health restrict infant formulas packaged in BPA lined containers? And if you’re going to be BPA-free, how free do you need to be?

While I respect Dr. Beilensen’s stand on the issue, his department’s broad statement on BPA is as likely to fuel public hysteria as it is to positively influence the indigent children of Howard County. And while I agree with their policy as it pertains to bottles, their commitment to go BPA-free will need to address the issue of when, where and how much is too much (aka, the packaging issue) as well as the real risk of non-oral exposure. And he will inevitably need to explain to the citizens of Howard County that there are more questions to be answered before public health policy can be chiseled in stone.

Here are the facts: babies go through a very transient period where their production of lactase (the bowel enzyme necessary for digestion of lactose) is subpar. Beyond this very early and temporary period, babies tolerate lactose just fine. There are a handful of babies in recorded medical history who have been born without lactase. And unless you’ve birthed one of these half-dozen babies, your baby shouldn’t need a lactose-free formula. One exception: viruses may injure the lining of the small bowel to the point where lactase can be temporarily lost. While some pediatricians will recommend going lactose-free during this time period, there’s little evidence that it actually improves a baby’s course of diarrhea. And soy formulas for generations have covered the waterfront just fine – they’re lactose-free.

And while there will always be those who claim that lactose-free formula “saved their baby’s life”, there will also be those who suggest that switching from Similac to Enfamil had the same impact. Infant formula urban legends are complicated and what some parents report is truly hard to reconcile. I can say this as a father and a pediatrician.

As someone who makes a living caring for babies with fragile tummies, I can attest to the fact that presence of lactose-free formula on grocery store shelves serves to confuse parents. And in some cases this confusion fuels the game of formula roulette. While I won’t go so far as to call the marketing of lactose-free formula irresponsible, I will suggest that it should go the way of low-iron formula. It represents a market-driven product that doesn’t serve the needs of its customer, the baby. Further, its empty promise of soothing “colic” serves only to bamboozle desperate parents who think that it might make a difference.

Overheat it. Excessive heat will damage vitamins and protein (ditto freezing). Heat in warm water for 10 minutes or so and remember that cold formula has yet to kill a baby. And while everyone’s done it from time to time, avoid the microwave.

Make your own recipes. Don’t think you’re smarter than Mead Johnson or Abbott, prepare formula as instructed. Adding less water, for example, to help your baby gain weight should only be done under the direction of a professional. The wrong mixture can lead to dangerous levels of minerals.

Let it sit. Prepared or opened infant formula should never be allowed to sit at room temperature for more than two hours. Sugar and warmth = growth of the weird and wonderful. In the fridge, formula is good for about 24 hours. When in doubt, throw it out.

Play roulette. Unless your baby has clear signs of milk protein allergy, there’s likely little to be gained from formula roulette. Gamble at will, but remember: Babies have symptoms for a reason and formula change is rarely the answer.

Dump it at the airline security gate. According to TSA breast milk and formula in quantities exceeding 3 ounces may be brought onboard and airplane so long as it is declared at the security checkpoint. And no, you don’t have to taste it in front of the TSA agent.

Just when you thought it was safe to go back to the formula aisle, Mead Johnson introduces Nutramigen AA. This is an amino acid-based infant formula for babies with severe milk protein allergy. Amino acid-based formulas differ from standard formulas in that their protein is treated and completely broken down into its most basic element, the amino acid (thus the “AA” in the name). Nutramigen AA will take its place next to two amino acid-based infant formulas currently available on the market, Neocate and Elecare. These formulas are sometimes called elemental or ultrahydrolyzed formulas.

So does Nutramigen AA bring anything new to the table? It wouldn’t appear that way. From a protein allergy perspective, all three amino acid-based formulas on the market are identical – after all, totally broken down protein is totally broken down protein. It doesn’t get any more basic than that. SHS, the manufacturer of Neocate, does suggest that their product is the only amino acid-based formula manufactured in a 100% dairy-free environment. Otherwise, there are some slight differences in the fat composition between the three, but this is unlikely to be relevant for most babies. Nutramigen AA has higher levels of DHA than Neocate and Elecare although all meet minimum standards for DHA/ARA.

So who needs an amino acid-based formula? Babies with severe milk protein allergy who have failed an adequate trial of extensively hydrolysed formula (EHF) such as Alimentum or Nutramigen. If protein allergy has been diagnosed on clinical grounds (some combination of diarrhea, bleeding, cramping / “colic”, feeding intolerance, eczematous rash, elevated eosinophils in the blood and failure to thrive) and a trial of EHF formula has failed to change a baby’s clinical status after 3-4 weeks, an amino acid-based formula may be indicated. In some cases we consider endoscopy to confirm the diagnosis before committing a family to a $600/month formula habit.

Here’s my concern: Amino acid-based formulas are infrequently indicated during infancy. But desperate docs make desperate changes when faced with desperate parents. And with a competitive field of formulas, aggressive marketing could push their use beyond what’s really necessary. Formula roulette can be costly if severe, intractable protein allergy hasn’t been firmly established. Infant formula demand is often supplier induced – look at lactose-free and low-iron formula. Hopefully parents and doctors won’t be lured where they don’t belong.

On the upside, competition in the formula marketplace can create the potential for cost savings to parents. That is, of course, if Neocate and its Spartan sales force can sustain itself against Mead Johnson’s marketing machine. Don’t touch that dial.

The American Academy of Pediatrics today issued a clinical report to guide early feeding for children at risk for allergy. Breast-feeding again comes out on top but contrary to advice offered in 2000, food avoidance during pregnancy is no longer a concern. The clinical report if nothing else serves as an excellent review of what’s known about early feeding and the risk for allergy.

Here are the take home points:

1. The restriction of peanuts or other foods during pregnancy or breast-feeding doesn’t lower a child’s risk of allergies.
2. For infants with a family history of allergy, exclusive breast-feeding for at least 4 months can lessen the risk of cow milk allergy early in life.
3. Among formula fed infants at risk for developing allergies there is evidence that allergy be delayed or prevented by the use of partially hydrolysed formulas (Nutramigen, Alimentum, Good Start).
4. Soy-based infant formula has no role allergy prevention.
5. There is no convincing evidence that delaying the introduction of solids beyond 4-6 months has any effect on preventing allergy.

Beyond the part about giving mom free reign to enjoy a PayDay bar, the recommendation of hydrolysed formula for non breast-feeding babies at risk for allergy is interesting. As a man on the street (or clinic in my case) I would say that this isn’t anywhere near the standard of care and it’ll be interesting to see if the pediatricians pick up on it.

Last week I recommended Carnation Good Start with Natural Cultures to mother who had visited my office. She had considered Good Start but sheepishly confessed that she discounted it when she found it was less expensive than the competitor. It seems some parents believe a high price tag formula holds some advantage for their baby.

Are there cases where it’s a good idea to spend more for formula? Very few. Here are a few situations where you can expect formula to come at a higher cost:

Allergy. Hydrolysed formulas such as Nutramigen and Alimentum are costly to prepare and consequently come at a higher cost. Expect to pay about 350 dollars a month to feed your typical 4-month-old baby with hydrolysed formula. Extensively hydrolysed formulas such as Neocate are more expensive and will cost over 500 dollers per month for the typical 4-month-old baby. In each of these cases there’s no advantage to their use unless your baby is truly suffering with milk protein allergy.

Magic fat. And what about DHA and ARA? These are the long-chained polyunsaturated fatty acids (LCPUFAs) found in breast milk that have been associated improved visual and cognitive function in newborns. While these were once an option for formula shopping parents, most manufacturers produce formula with DHA and ARA. While the argument against LCPUFAs in infant formula is losing steam I recommend a formula with adequate levels of DHA/ARA for those who can’t breastfeed. In this regard I like Good Start Supreme with DHA and ARA and Enfamil Lipil.

Organics. Organic infant formulas come at a higher cost but its unclear whether the degree of ‘contamination’ found in standard infant formula makes the step to organic worth it. Interestingly, Similac markets an organic baby formula and it makes me wonder why would you by the ‘dirty’ Similac when you can have the virginal organic preparation. Gerber faced this issue early on when organic baby foods first hit the shelves. They solved this issue by offering organic baby dinners with names that were entirely different from their standard line of jarred food. Parents never felt the obvious dilemma. Brilliant.

Convenience. Preparations of formula, of course, will vary with ready-to-feed formula being the most expensive. This is pure preference. But despite my insistence that there will be no difference for your baby among powder, concentrate or ready-to-feed, I often encounter parents with stories of intolerance with one form and not the other.

In the case of my patient and her reluctance to use Good Start, the difference in cost reflected differences in marketing, not nutrition. Finally, it’s interesting that I often run into parents looking for ‘permission’ to use the less expensive Parent’s Choice. As an aside, Parent’s Choice represents a fine option for parents seeking a more economical feeding option. While it may lack the live passengers found in Good Start with Natural Cultures, cost in this case shouldn’t otherwise represent a compromise.

Preemies take note: Abbott’s Ross Product division has recalled 3 lots of Similac Special Care Ready-to-Feed formula for iron levels that don't match those of the label.

The recall is limited to stock code number 59582 with lot numbers 46815D5, 47847D5 or 52023D5 printed on the outside carton and case and the lot numbers 44427X8, 44427X81 or 50005X8 printed on the bottom of the bottles. No other liquid or powdered Similac infant formulas are affected.